Community Resources addressing Social Determinants of Health

(appreciate help from Montefiore Internal Medicine Residency Program and Dr. A Vassilakis, AIM alum)


Meals on wheels

·         Must be 60 and over have a physical or mental disability that prevents pt from shopping or preparing food.

·         Cannot have Medicaid home care, home care worker, or family members who assit patient with meals or meal prep

·         Meals on wheels near you


Senior centers

·         Some centers provide free meals to those 60+

·         Senior Centers near you



·         Physicians can write a letter to electricity providers to avoid cut off with medical use (Az, OSA, meds needing refrig.)


Lifeline “obamaphone

·         Mobile phone assistance program for low income

·         A federal program but eligibility determined by states, candidates often have Medicaid SNAP SSI

·         Info link here



·         Poor condition

o   Provider can write a letter to landlord indicating impact of condition on pt’s health

o   Pt can file complaint with 311

·         Eviction

o   There may be “one shot deal” from local municipalities to assist with one time rent payment; search for legal services

·         Emergency

o   Homeless shelter referrals- shelter are split based on single adult male/females, adult families, and families with children.

o   Shelter often have strict intake times and limited availabilities.


Transportation to clinic

·         One time assistance-one time metrocard- depends on insurance company.  

·         Pt can take Public transportation -Reduced fare for those over 65, on ssi or ssd. Need to get form from MTA. PCP may need to attest medical reasons.   

·         Pt can not take bus/subway- Access-a-Ride- provides semi private txp for pts who can not take public transportation. Pt must call  877 337 2017 to schedule eligibility appointment. PCP must write documentation of disability letter with access-a-ride form.

·         If pt has Medicaid and physically can not ride public transportation or access-a-ride, more eligibility info for SW can assist in application. Pt need to call  877 564 5922 to set up appt 3 days before appt.